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Thank you for your question. Unfortunately, there is no simple
answer as to when the medical work-up should be considered complete, and I
suspect that pediatricians would not be likely to agree completely on what
would constitute a reasonable “boilerplate” medical assessment for
pediatric recurrent abdominal pain (RAP). The facts of each case must be
evaluated individually, and it may be impossib...

Thank you for your question. Unfortunately, there is no simple
answer as to when the medical work-up should be considered complete, and I
suspect that pediatricians would not be likely to agree completely on what
would constitute a reasonable “boilerplate” medical assessment for
pediatric recurrent abdominal pain (RAP). The facts of each case must be
evaluated individually, and it may be impossible to absolutely and
definitively rule-out unrecognized disease in many children with
ostensibly unexplained RAP. The clinician must strive for a balance
between the importance of minimizing professional anxiety about
unrecognized physical disease, family anxiety, the risks of medical tests
and procedures, and cost. In general, unless the professional is
reasonably comfortable that a serious physical disease has not been missed
and is able to communicate this conviction to the patient and family, it
will be difficult to provide credible reassurance to the patient and
family that physical disease has not been overlooked.1 Unnecessary medical
tests and treatments can be dangerous in and of themselves, and have the
potential to communicate physician uncertainty and thus generate
unnecessary patient and family anxieties. A functional diagnosis should
not be made by excluding physical disease alone, but the clinician should
look for “clues” or positive findings, with the more prominent being
contiguity of the symptom with psychosocial stressors, the presence of a
diagnosable psychiatric disorder, association of the symptom with
psychological gain for the child, existence of a model for the symptom
within the child’s immediate environment, and responsiveness of the
symptom to placebo, suggestion, or psychological treatment.2-5 Such
“clues” are certainly not definitive. A constellation of “clues” taken
together is most persuasive, but do not exclude the possibility that
physical disease may be present. The clinician should certainly perform a
focused psychiatric interview with the child and parent, and ask relevant
questions about persistent fears, worries, and depressive symptoms.

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